Chapter 12: Schizophrenia Spectrum Disorder
A patient insistently states, "I can decipher codes of DNA just by looking at someone." Which problem is evident a.Visual hallucinations b.Magical thinking c.Idea of reference d.Thought insertion
Magical thinking Magical thinking is evident in the patient's appraisal of his own abilities. There is no evidence of the distracters.
A patient receiving risperidone (Risperdal) reports severe muscle stiffness at 1030. By 1200, the patient has difficulty swallowing and is drooling. By 1600, vital signs are 102.8° F; pulse 110; respirations 26; 150/90. The patient is diaphoretic. Select the nurse's best analysis and action. a.Agranulocytosis; institute reverse isolation. b.Tardive dyskinesia; withhold the next dose of medication. c.Cholestatic jaundice; begin a high-protein, high-cholesterol diet. d.Neuroleptic malignant syndrome; notify health care provider stat.
Neuroleptic malignant syndrome; notify health care provider stat. Taking an antipsychotic medication coupled with the presence of extrapyramidal symptoms, such as severe muscle stiffness and difficulty swallowing, hyperpyrexia, and autonomic symptoms (pulse elevation), suggest neuroleptic malignant syndrome, a medical emergency. The symptoms given in the scenario are not consistent with the medical problems listed in the incorrect options.
A nurse asks a patient diagnosed with schizophrenia, "What is meant by the old saying 'You can't judge a book by looking at the cover.'" Which response by the patient indicates concrete thinking a."The table of contents tells what a book is about." b."You can't judge a book by looking at the cover." c."Things are not always as they first appear." d."Why are you asking me about books"
"The table of contents tells what a book is about." Concrete thinking refers to an impaired ability to think abstractly. Concreteness is often assessed through the patient's interpretation of proverbs. Concreteness reduces one's ability to understand and address abstract concepts such as love or the passage of time. The incorrect options illustrate echolalia, an unrelated question, and abstract thinking.
A person has had difficulty keeping a job because of arguing with co-workers and accusing them of conspiracy. Today the person shouts, "They're all plotting to destroy me. Isn't that true" Select the nurse's most therapeutic response. a."Everyone here is trying to help you. No one wants to harm you." b."Feeling that people want to destroy you must be very frightening." c."That is not true. People here are trying to help you if you will let them." d."Staff members are health care professionals who are qualified to help you."
"Feeling that people want to destroy you must be very frightening." Resist focusing on content; instead, focus on the feelings the patient is expressing. This strategy prevents arguing about the reality of delusional beliefs. Such arguments increase patient anxiety and the tenacity with which the patient holds to the delusion. The other options focus on content and provide opportunity for argument.
A patient diagnosed with schizophrenia tells the nurse, "I eat skiller. Tend to end. Easter. It blows away. Get it" Select the nurse's best response. a."Nothing you are saying is clear." b."Your thoughts are very disconnected." c."Try to organize your thoughts and then tell me again." d."I am having difficulty understanding what you are saying."
"I am having difficulty understanding what you are saying." When a patient's speech is loosely associated, confused, and disorganized, pretending to understand is useless. The nurse should tell the patient that he or she is having difficulty understanding what the patient is saying. If a theme is discernible, ask the patient to talk about the theme. The incorrect options tend to place blame for the poor communication with the patient. The correct response places the difficulty with the nurse rather than being accusatory.
A newly admitted patient diagnosed with schizophrenia says, "The voices are bothering me. They yell and tell me I am bad. I have got to get away from them." Select the nurse's most helpful reply. a."Do you hear the voices often" b."Do you have a plan for getting away from the voices" c."I'll stay with you. Focus on what we are talking about, not the voices. " d."Forget the voices and ask some other patients to play cards with you."
"I'll stay with you. Focus on what we are talking about, not the voices. " Staying with a distraught patient who is hearing voices serves several purposes: ongoing observation, the opportunity to provide reality orientation, a means of helping dismiss the voices, the opportunity of forestalling an action that would result in self-injury, and general support to reduce anxiety. Asking if the patient hears voices is not particularly relevant at this point. Asking if the patient plans to "get away from the voices" is relevant for assessment purposes but is less helpful than offering to stay with the patient while encouraging a focus on their discussion. Suggesting playing cards with other patients shifts responsibility for intervention from the nurse to the patient and other patients.
Which hallucination necessitates the nurse to implement safety measures The patient says, a."I hear angels playing harps." b."The voices say everyone is trying to kill me." c."My dead father tells me I am a good person." d."The voices talk only at night when I'm trying to sleep."
"The voices say everyone is trying to kill me." The correct response indicates the patient is experiencing paranoia. Paranoia often leads to fearfulness, and the patient may attempt to strike out at others to protect self. The distracters are comforting hallucinations or do not indicate paranoia.
A patient diagnosed with schizophrenia and auditory hallucinations anxiously tells the nurse, "The voice is telling me to do things." Select the nurse's priority assessment question. a."How long has the voice been directing your behavior" b."Does what the voice tell you to do frighten you" c."Do you recognize the voice speaking to you' d."What is the voice telling you to do"
"What is the voice telling you to do" Learning what a command hallucination is telling the patient to do is important because the command often places the patient or others at risk for harm. Command hallucinations can be terrifying and may pose a psychiatric emergency. The incorrect questions are of lesser importance than identifying the command.
A nurse sits with a patient diagnosed with schizophrenia. The patient starts to laugh uncontrollably, although the nurse has not said anything funny. Select the nurse's best response. a."Why are you laughing" b."Please share the joke with me." c."I don't think I said anything funny." d."You're laughing. Tell me what's happening."
"You're laughing. Tell me what's happening."
A nurse at the mental health clinic plans a series of psychoeducational groups for persons newly diagnosed with schizophrenia. Which two topics take priority a."The importance of taking your medication correctly" b."How to complete an application for employment" c."How to dress when attending community events" d."How to give and receive compliments" e."Ways to quit smoking"
-"The importance of taking your medication correctly" -"Ways to quit smoking"
A patient diagnosed with schizophrenia was hospitalized after arguing with co-workers and threatening to harm them. The patient is aloof, suspicious, and says, "Two staff members I saw talking were plotting to kill me." Based on data gathered at this point, which nursing diagnoses relate Select all that apply. a.Risk for other-directed violence b.Disturbed thought processes c.Risk for loneliness d.Spiritual distress e.Social isolation
-Risk for other-directed violence -.Disturbed thought processes
An acutely violent patient diagnosed with schizophrenia receives several doses of haloperidol (Haldol). Two hours later the nurse notices the patient's head rotated to one side in a stiffly fixed position, the lower jaw thrust forward, and drooling. Which intervention by the nurse is indicated a.Administer diphenhydramine (Benadryl) 50 mg IM from the PRN medication administration record. b.Reassure the patient that the symptoms will subside. Practice relaxation exercises with the patient. c.Give trihexyphenidyl (Artane) 5 mg orally at the next regularly scheduled medication administration time. d.Administer atropine sulfate 2 mg subcut from the PRN medication administration record.
Administer diphenhydramine (Benadryl) 50 mg IM from the PRN medication administration record. Diphenhydramine, trihexyphenidyl, benztropine, and other anticholinergic medications may be used to treat dystonias. Swallowing will be difficult or impossible; therefore, oral medication is not an option. Medication should be administered immediately, so the intramuscular route is best. In this case, the best option given is diphenhydramine.
A patient is experiencing delusions of persecution about being poisoned. The patient has refused all hospital meals for 3 days. Which intervention is most likely to be acceptable to the patient a.Allowing the patient supervised access to food vending machines b.Allowing the patient to phone a local restaurant to deliver meals c.Offering to taste each portion on the tray for the patient d.Providing tube feedings or total parenteral nutrition
Allowing the patient supervised access to food vending machines
A patient diagnosed with schizophrenia is very disturbed and violent. After several doses of haloperidol (Haldol), the patient is calm. Two hours later the nurse sees the patient's head rotated to one side in a stiff position, the lower jaw thrust forward, and drooling. Which problem is most likely a.An acute dystonic reaction b.Tardive dyskinesia c.Waxy flexibility d.Akathisia
An acute dystonic reaction Acute dystonic reactions involve painful contractions of the tongue, face, neck, and back. Opisthotonos and oculogyric crisis may be observed. Dystonic reactions are considered emergencies requiring immediate intervention. Tardive dyskinesia involves involuntary spasmodic muscular contractions that involve the tongue, fingers, toes, neck, trunk, or pelvis. It appears after prolonged treatment. Waxy flexibility is a symptom seen in catatonic schizophrenia. Internal and external restlessness, pacing, and fidgeting are characteristics of akathisia.
A health care provider considers which antipsychotic medication to prescribe for a patient diagnosed with schizophrenia who has auditory hallucinations and poor social function. The patient is also overweight and hypertensive. Which drug should the nurse advocate a.Clozapine (Clozaril) b.Ziprasidone (Geodon) c.Olanzapine (Zyprexa) d.Aripiprazole (Abilify)
Aripiprazole (Abilify) Aripiprazole is a third-generation atypical antipsychotic effective against both positive and negative symptoms of schizophrenia. It causes little or no weight gain and no increase in glucose, high- or low-density lipoprotein cholesterol, or triglycerides, making it a reasonable choice for a patient with obesity or heart disease. Clozapine may produce agranulocytosis, making it a poor choice as a first-line agent. Ziprasidone may prolong the QT interval, making it a poor choice for a patient with cardiac disease. Olanzapine fosters weight gain.
A patient diagnosed with schizophrenia says, "It's beat. Time to eat. No room for the cat." What type of verbalization is evident a.Neologism b.Idea of reference c.Thought broadcasting d.Associative looseness
Associative looseness Looseness of association refers to jumbled thoughts incoherently expressed to the listener. Neologisms are newly coined words. Ideas of reference are a type of delusion. Thought broadcasting is the belief that others can hear one's thoughts.
A patient diagnosed with schizophrenia says, "My co-workers are out to get me. I also saw two doctors plotting to kill me." How does this patient perceive the environment a.Disorganized b.Dangerous c.Supportive d.Bizarre
Dangerous The patient sees the world as hostile and dangerous. This assessment is important because the nurse can be more effective by using empathy to respond to the patient. Data are not present to support any of the other options.
A patient's care plan includes monitoring for auditory hallucinations. Which assessment findings suggest the patient may be hallucinating a.Detachment and overconfidence b.Darting eyes, tilted head, mumbling to self c.Euphoric mood, hyperactivity, distractibility d.Foot tapping and repeatedly writing the same phrase
Darting eyes, tilted head, mumbling to self Clues to hallucinations include eyes looking around the room as though to find the speaker, tilting the head to one side as though listening intently, and grimacing, mumbling, or talking aloud as though responding conversationally to someone.
A patient diagnosed with schizophrenia has taken a conventional antipsychotic medication for a year. Hallucinations are less intrusive, but the patient continues to have apathy, poverty of thought, and social isolation. The nurse would expect a change to which medication a.Haloperidol (Haldol) b.Olanzapine (Zyprexa) c.Chlorpromazine (Thorazine) d.Diphenhydramine (Benadryl)
Olanzapine (Zyprexa) Olanzapine is a second-generation atypical antipsychotic that targets both positive and negative symptoms of schizophrenia. Haloperidol and chlorpromazine are conventional antipsychotics that target only positive symptoms. Diphenhydramine is an antihistamine.
A patient diagnosed with schizophrenia says, "Contagious bacteria are everywhere. When they get in your body, you will be locked up with other infected people." Which problem is evident a.Poverty of content b.Concrete thinking c.Neologisms d.Paranoia
Paranoia The patient's unrealistic fear of harm indicates paranoia. Neologisms are invented words. Concrete thinking involves literal interpretation. Poverty of content refers to an inadequate fund of information.
A patient diagnosed with schizophrenia exhibits little spontaneous movement and demonstrates waxy flexibility. Which patient needs are of priority importance a.Self-esteem b.Psychosocial c.Physiological d.Self-actualization
Physiological Physiological needs must be met to preserve life. A patient with waxy flexibility must be fed by hand or tube, toileted, given range-of-motion exercises, and so forth to preserve physiological integrity. Waxy flexibility may also precipitate a risk for falls; therefore, safety is a concern. Higher level needs are of lesser concern.
The nurse assesses a patient diagnosed with schizophrenia. Which assessment finding would the nurse regard as a negative symptom of schizophrenia a.Auditory hallucinations b.Delusions of grandeur c.Poor personal hygiene d.Psychomotor agitation
Poor personal hygiene Negative symptoms include apathy, anhedonia, poor social functioning, and poverty of thought. Poor personal hygiene is an example of poor social functioning. The distracters are positive symptoms of schizophrenia. See relationship to audience response question.
Which finding constitutes a negative symptom associated with schizophrenia a.Hostility b.Bizarre behavior c.Poverty of thought d.Auditory hallucinations
Poverty of thought
A patient diagnosed with schizophrenia has taken fluphenazine (Prolixin) 5 mg po bid for 3 weeks. The nurse now observes a shuffling propulsive gait, a mask-like face, and drooling. Which term applies to these symptoms a.Neuroleptic malignant syndrome b.Hepatocellular effects c.Pseudoparkinsonism d.Akathisia
Pseudoparkinsonism Pseudoparkinsonism induced by antipsychotic medication mimics the symptoms of Parkinson's disease. It frequently appears within the first month of treatment and is more common with first-generation antipsychotic drugs. Hepatocellular effects would produce abnormal liver test results. Neuroleptic malignant syndrome is characterized by autonomic instability. Akathisia produces motor restlessness.
The family of a patient diagnosed with schizophrenia is unfamiliar with the illness and family's role in recovery. Which type of therapy should the nurse recommend a.Psychoeducational b.Psychoanalytic c.Transactional d.Family
Psychoeducational A psychoeducational group explores the causes of schizophrenia, the role of medication, the importance of medication compliance, support for the ill member, and hints for living with a person with schizophrenia. Such a group can be of immeasurable practical assistance to the family. The other types of therapy do not focus on psychoeducation.
When a patient diagnosed with schizophrenia was discharged 6 months ago, haloperidol (Haldol) was prescribed. The patient now says, "I stopped taking those pills. They made me feel like a robot." What are common side effects the nurse should validate with the patient a.Sedation and muscle stiffness b.Sweating, nausea, and diarrhea c.Mild fever, sore throat, and skin rash d.Headache, watery eyes, and runny nose
Sedation and muscle stiffness Typical antipsychotic drugs often produce sedation and extrapyramidal side effects such as stiffness and gait disturbance, effects the patient might describe as making him or her feel like a "robot." The side effects mentioned in the other options are usually not associated with typical antipsychotic therapy or would not have the effect described by the patient.
A patient took trifluoperazine 30 mg po daily for 3 years. The clinic nurse notes that the patient grimaces and constantly smacks both lips. The patient's neck and shoulders twist in a slow, snakelike motion. Which problem would the nurse suspect a.Agranulocytosis b.Tardive dyskinesia c.Tourette's syndrome d.Anticholinergic effects
Tardive dyskinesia Fluphenazine decanoate is a first-generation antipsychotic medication. Tardive dyskinesia is a condition involving the face, trunk, and limbs that occurs more frequently with first-generation antipsychotics than second or third generation. Involuntary movements, such as tongue thrusting; licking; blowing; irregular movements of the arms, neck, and shoulders; rocking; hip jerks; and pelvic thrusts, are seen. These symptoms are frequently not reversible even when the drug is discontinued. The scenario does not present evidence consistent with the other disorders mentioned. Agranulocytosis is a blood disorder. Tourette's syndrome is a condition in which tics are present. Anticholinergic effects include dry mouth, blurred vision, flushing, constipation, and dry
A client says, "Facebook has a new tracking capacity. If I use the Internet, Homeland Security will detain me as a terrorist." Select the nurse's best initial action. a.Tell the client, "Facebook is a safe website. You don't need to worry about Homeland Security." b.Tell the client, "You are in a safe place where you will be helped." c.Administer a prn dose of an antipsychotic medication. d.Tell the client, "You don't need to worry about that."
Tell the client, "You are in a safe place where you will be helped."
A community mental health nurse wants to establish a relationship with a very withdrawn patient diagnosed with schizophrenia. The patient lives at home with a supportive family. Select the nurse's best plan. a.Visit daily for 4 days, then every other day for 1 week; stay with patient for 20 minutes, accept silence; state when the nurse will return. b.Arrange to spend 1 hour each day with the patient; focus on asking questions about what the patient is thinking or experiencing; avoid silences. c.Visit twice daily; sit beside the patient with a hand on the patient's arm; leave if the patient does not respond within 10 minutes. d.Visit every other day; remind the patient of the nurse's identity; encourage the patient to talk while the nurse works on reports.
Visit daily for 4 days, then every other day for 1 week; stay with patient for 20 minutes, accept silence; state when the nurse will return.
A nurse observes a catatonic patient standing immobile, facing the wall with one arm extended in a salute. The patient remains immobile in this position for 15 minutes, moving only when the nurse gently lowers the arm. What is the name of this phenomenon a.Echolalia b.Waxy flexibility c.Depersonalization d.Thought withdrawal
Waxy flexibility Waxy flexibility is the ability to hold distorted postures for extended periods of time, as though the patient were molded in wax. Echolalia is a speech pattern. Depersonalization refers to a feeling state. Thought withdrawal refers to an alteration in thinking.
A patient diagnosed with schizophrenia begins a new prescription for lurasidone HCL (Latuda). The patient is 5'6" and currently weighs 204 lbs. Which topic is most important for the nurse to include in the teaching plan related to this medication a.How to recognize tardive dyskinesia b.Weight management strategies c.Ways to manage constipation d.Sleep hygiene measures
Weight management strategies Ziprasidone is a second-generation antipsychotic medication. The incidence of weight gain, diabetes, and high cholesterol is high with second-generation antipsychotic medications. The patient is overweight now, so weight management will be especially important. The other interventions may occur in time, but do not have the priority of weight management.
What assessment findings mark the prodromal stage of schizophrenia a.Withdrawal, misinterpreting, poor concentration, and preoccupation with religion b.Auditory hallucinations, ideas of reference, thought insertion, and broadcasting c.Stereotyped behavior, echopraxia, echolalia, and waxy flexibility d.Loose associations, concrete thinking, and echolalia neologisms
Withdrawal, misinterpreting, poor concentration, and preoccupation with religion Withdrawal, misinterpreting, poor concentration, and preoccupation with religion are prodromal symptoms, the symptoms that are present before the development of florid symptoms. The incorrect options each list the positive symptoms of schizophrenia that might be apparent during the acute stage of the illness.
A patient diagnosed with schizophrenia begins to talks about "macnabs" hiding in the warehouse at work. The term "macnabs" should be documented as: a.a neologism. b.concrete thinking. c.thought insertion. d.an idea of reference.
a neologism. A neologism is a newly coined word having special meaning to the patient. "Macnabs" is not a known common word. Concrete thinking refers to the inability to think abstractly. Thought insertion refers to thoughts of others are implanted in one's mind. Ideas of reference are a type of delusion in which trivial events are given personal significance.
A newly admitted patient diagnosed with schizophrenia is hypervigilant and constantly scans the environment. The patient states, "I saw two doctors talking in the hall. They were plotting to kill me." The nurse may correctly assess this behavior as: a.echolalia. b.an idea of reference. c.a delusion of infidelity. d.an auditory hallucination.
an idea of reference. Ideas of reference are misinterpretations of the verbalizations or actions of others that give special personal meanings to these behaviors; for example, when seeing two people talking, the individual assumes they are talking about him or her. The other terms do not correspond with the scenario.
Withdrawn patients diagnosed with schizophrenia: a.are usually violent toward caregivers. b.universally fear sexual involvement with therapists. c.exhibit a high degree of hostility as evidenced by rejecting behavior. d.avoid relationships because they become anxious with emotional closeness.
avoid relationships because they become anxious with emotional closeness.
The nurse is developing a plan for psychoeducational sessions for several adults diagnosed with schizophrenia. Which goal is best for this group Members will: a.gain insight into unconscious factors that contribute to their illness. b.explore situations that trigger hostility and anger. c.learn to manage delusional thinking. d.demonstrate improved social skills.
demonstrate improved social skills.
A patient diagnosed with schizophrenia anxiously says, "I can see the left side of my body merging with the wall, then my face appears and disappears in the mirror." While listening, the nurse should: a.sit close to the patient. b.place an arm protectively around the patient's shoulders. c.place a hand on the patient's arm and exert light pressure. d.maintain a normal social interaction distance from the patient.
maintain a normal social interaction distance from the patient. The patient is describing phenomena that indicate personal boundary difficulties and depersonalization. The nurse should maintain appropriate social distance and not touch the patient because the patient is anxious about the inability to maintain ego boundaries and merging or being swallowed by the environment. Physical closeness or touch could precipitate panic.
A patient diagnosed with schizophrenia demonstrates little spontaneous movement and has waxy flexibility. The patient's activities of daily living are severely compromised. An appropriate outcome would be that the patient will: a.demonstrate increased interest in the environment by the end of week 1. b.perform self-care activities with coaching by the end of day 3. c.gradually take the initiative for self-care by the end of week 2. d.accept tube feeding without objection by day 2.
perform self-care activities with coaching by the end of day 3 Outcomes related to self-care deficit nursing diagnoses should deal with increasing ability to perform self-care tasks independently, such as feeding, bathing, dressing, and toileting. Performing the tasks with coaching by nursing staff denotes improvement over the complete inability to perform the tasks. The incorrect options are not directly related to self-care activities, difficult to measure, and unrelated to maintenance of nutrition.
A patient diagnosed with schizophrenia has been stable for a year; however, the family now reports the patient is tense, sleeps 3 to 4 hours per night, and has difficulty concentrating. The patient says, "My computer is sending out infected radiation beams." The nurse can correctly assess this information as an indication of: a.the need for psychoeducation. b.medication noncompliance. c.chronic deterioration. d.relapse.
relapse. Signs of potential relapse include feeling tense, difficulty concentrating, trouble sleeping, increased withdrawal, and increased bizarre or magical thinking. Medication nonadherence may not be implicated. Relapse can occur even when the patient is taking medication regularly. Psychoeducation is more effective when the patient's symptoms are stable. Chronic deterioration is not the best explanation.